Cultural adaptation of the postpartum depression literacy scale: A pilot study

INTRODUCTION

According to the World Health Organization, almost 1 in 5 women is estimated to suffer from mental health conditions during pregnancy or in the year after childbirth.^[1] The most common mental disorder that affects women following childbirth is postpartum depression (PPD).^[2] The perinatal period is characterized by a dynamic interplay of biological, psychological, and social factors that make women more susceptible to depression.^[2] PPD typically begins to manifest within 2–8 weeks after childbirth, but it can also develop up to a year later. PPD affects approximately 17.22% of postpartum women globally, and a recent meta-analysis in India found an even higher prevalence of about 22%.^[3,4]

Symptoms of PPD include the inability to experience pleasure, spontaneous crying, appetite and sleep disturbances, fatigue, impaired attention and concentration, feelings of guilt and despair, and even suicidal thoughts.^[5] Several risk factors contribute to a new mother’s susceptibility to PPD in India, such as low maternal education, personal or familial histories of mental health disorders, exposure to adverse life events, complications during pregnancy and childbirth, giving birth to a female child, domestic violence, financial difficulties, and lack of support from spouse and family members. PPD not only affects mothers but also has negative consequences on the emotional, cognitive, and social development of the child.^[4,6-9]

Several studies in India reveal that the prevalence of PPD varies from 15.8% to 48.5%. Despite its high prevalence, the diagnostic rate remains poor, with only about 40% of affected women receiving a diagnosis.^[10] A major barrier to seeking care is the lack of awareness regarding PPD and its treatment options.^[11,12] This underscores the importance of having accurate knowledge and appropriate attitudes toward PPD among women to enable early recognition, help seeking, and access to treatment.^[11]

Jorm has defined mental health literacy (MHL) as the knowledge and beliefs that facilitate the recognition, management, and prevention of mental disorders.^[13] Enhancing maternal MHL can improve women’s perceptions of PPD, foster trust in maternal mental health services, and support overall maternal well-being. Research highlights that poor MHL is a significant barrier to seeking professional help and low PPD literacy among mothers may minimize or normalize their symptoms, thus delaying access to treatment.^[14] To address the same, Mirsalimi et al.^[15]developed the Postpartum Depression Literacy Scale (PoDLiS), a self-report tool in the English language, designed to assess PPD literacy during the perinatal period. PoDLiS, which aligns with the broader concept of MHL, has demonstrated strong validity and reliability^[15] and has been successfully administered in countries such as Iran, India, China, Saudi Arabia, and Malaysia.^[16-20]

Despite the proven reliability of PoDLiS, its validity across different cultural contexts remains uncertain. The scale has been currently adapted and validated among a few languages such as Chinese and Arabic. India is known for its cultural diversity and variations in languages spoken across different states, which necessitates the compelling need to translate and validate the PoDLiS in the Indian cultural context. The study by Poreddi et al. in India revealed that only half of the postpartum mothers had adequate PPD literacy.^[16] Thus, it is crucial to promote maternal MHL to improve the well-being of mothers. According to the 2011 census, the vernacular language Kannada was the eighth most spoken language in India with 43.7 million speakers.^[21] The research on PPD literacy among postpartum mothers in India remains limited, partly due to the non-availability of a translated and validated literacy tool for the Indian context. To address the same, the current study aims to translate and culturally adapt PoDLiS into Kannada and determine its validity and reliability.

MATERIALS AND METHODS

Instrument adaptation

Formal permission was sought from the authors to translate and use the English version of PoDLiS into Kannada for this study.

Forward and back translation

The PoDLiS was translated into Kannada language for the assessment of PPD literacy. Following the initial forward translation, the tool was provided to subject matter experts, who independently performed a back-translation into English. The translated Kannada version was subsequently reviewed by the research team, who provided detailed feedback. Revisions were made based on the feedback, and the final tool was made available for expert consultation.

Expert consultation

A total of five experts from the fields of Psychiatry, Clinical Psychology, Clinical Nursing, Psychiatry Social Work, and Public Health were approached for content validation of the translated tool using a 4-point Likert scale (1 being “not relevant” to 4 being “highly relevant”) and to provide their feedback. All of them were knowledgeable about PPD literacy and had more than 10 years of expertise in the field. A non-face-to-face method was employed by contacting experts online for the validation, accompanied by detailed instructions. Online method was chosen to get diverse views on the language, its applicability, and linguistic compatibility from experts across the state. Later, the revised version of the tool was finalized after incorporating the feedback from experts. The final version of translated tool in consensus with experts accepted all 31 items, with reverse coding of only item 14 to accommodate the cultural context. Figure 1 depicts the process of translation and adaptation of the PoDLiS in Kannada.

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Figure 1:

Flowchart depicting the process of translation and adaptation of the postpartum depression literacy scale in Kannada.

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RESULTS

Item analysis

Reliability

The PoDLiS-K was found to have an overall Cronbach’s alpha coefficient of 0.85, indicating good reliability. Cronbach’s alpha was also calculated for all 7 domains separately and found to range from 0.64 to 0.88. The first domain, which assessed the ability to identify PPD, had a Cronbach’s alpha coefficient of 0.83. The second, third, and fourth domains, which measured knowledge of risk factors and causes, knowledge, and beliefs of self-care activities and knowledge about the availability of professional help, had coefficients of 0.80, 0.83, and 0.81, respectively. For the fifth, sixth, and seventh domains, which measured beliefs about available professional help, attitudes facilitating the recognition of PPD and appropriate help seeking, and knowledge of how to seek information related to PPD, had coefficients of 0.89, 0.80, and 0.64, respectively. The same has been illustrated in Figure 2 and Table 2.

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Figure 2:

Cronbach’s alpha and content validity index scores of postpartum depression literacy scale-Kannada version. *PPD: Postpartum depression.

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Table 2: Cronbach’s alpha and CVI for PoDLiS-K domains.

S. No.	Domain	Cronbach’s α	CVI
1.	Ability to identify PPD	0.826	0.93
2.	Knowledge of risk factors and causes	0.801	1.00
3.	Knowledge and beliefs about self-care activities	0.578	1.00
4.	Knowledge about availability of professional help	0.809	0.80
5.	Beliefs about available professional help	0.868	0.80
6.	Attitudes facilitating recognition of PPD and appropriate help-seeking	0.797	1.00
7.	Knowledge of how to seek information related to PPD	0.638	0.84

CVI: Content validity index, PoDLiS-K: Postpartum depression literacy scale-Kannada version, PPD: Postpartum depression

Content validity

The average CVI of PoDLiS-K was calculated to be 0.94. The CVI of 7 domains of PoDLiS-K ranged between 0.8 and 1. For the first factor – the ability to identify PPD, the CVI was found to be 0.93, followed by a CVI of 1 for the second, third, and sixth factors, i.e., knowledge of risk factors and causes, knowledge and beliefs of self-care activities, and attitudes facilitating the recognition of the PPD. The CVI for the fourth and the fifth domains about the knowledge on availability of professional help and beliefs about available professional help was 0.8 and 0.89, respectively. For the seventh domain – knowledge of how to seek information related to PPD, the CVI was 0.84. The same has been illustrated in Table 2 and Figure 2.

DISCUSSION

PPD is a prevalent mental health disorder that significantly affects the well-being of mothers, infants, and families.^[4,24] The process of seeking help and obtaining a diagnosis for PPD is closely associated with PPD literacy,^[25] emphasizing the critical role of awareness and education in addressing the same. This was the first attempt to cross-culturally adapt and validate the PoDLiS for the Indian population by translating it into Kannada, a native language in Karnataka. The current study did not focus on establishing the domains and employed seven factors as outlined by Mirsalimi et al.,^[15] rather than the six constructs mentioned by Huang et al.,^[18] and AlAteeq et al.^[20] The PoDLiS-K demonstrated acceptable internal consistency and content validity, indicating that it is valid and reliable for assessing PPD literacy among mothers.

Cronbach’s alpha coefficient was used to calculate the internal consistency of the tool. It was measured at 0.85, which was higher than the original, Malay^[17] and Arabic versions^[20] but aligning more closely with the Chinese versions (C) of PoDLiS-C^[18] and C-PoDLiS.^[19] This suggests that the tool is effectively measuring the intended constructs across diverse cultural contexts. Among the seven domains analyzed, internal consistency was deemed satisfactory for most; however, the seventh domain on knowledge of seeking information on PPD exhibited a comparatively lower value of 0.64, as supported by a previous study by Poreddi et al. showing that around 50% of mothers did not have adequate PPD literacy.^[16] Further, item number 14, which represents religious practices, prayer, and going to church, is helpful for preventing or managing PPD and has been reverse coded in PoDLiS-K, attributing to the cultural and traditional healing practices for mental health conditions in India. These practices have been perceived as avenues for seeking faith healing rather than as self-care practices within the Indian context. There is also a strong belief among people in India that spiritual possession, invisible entities, or supernatural powers are the source of mental disorders.^[26,27] Usually, when someone in the community presents with mental illness, the family members first seek help from faith healers or religious places rather than reaching out to health professionals.^[28] Given this context, consultations with experts led to the decision to reverse code item 14 rather than excluding the item to understand the beliefs among mothers. This approach aims to elucidate the understanding that faith healers are not well-equipped to address mental health conditions effectively. In contrast, item 14 was deleted in the C-PoDLiS as the majority of the participants were nonreligious, and for most of them, religious activities could not be considered as self-care activities.

Notably, Cronbach’s alpha values for domains assessing the ability to identify PPD, knowledge of risk factors and causes, knowledge and beliefs about self-care activities, beliefs regarding professional help and attitudes promoting recognition of PPD, and appropriate help-seeking were all high for PoDLiS-K compared to those reported for the original tool,^[16] indicating this tool is most reliable for Indian settings. However, internal consistency for the domain related to knowledge of professional help remained consistent with the original tool’s findings. In addition, the domain focusing on knowledge regarding how to seek information related to PPD demonstrated lower internal consistency than its original counterpart and PoDLiS-C. This may possibly be due to a lack of awareness and accessible resources on PPD among postpartum mothers in India, which could prevent them from seeking information. These results suggest that the PoDLiS-K exhibits excellent internal consistency and applicability within the Indian context to better estimate PPD literacy among mothers in community settings. Future studies involving larger representative samples could focus on improving the less-scoring domains to ensure a comprehensive assessment and can also validate psychometric properties in other regional languages in India. Table 3 depicts a comparison of Cronbach’s alpha coefficients of this study with previous studies.

The CVI for the PoDLiS-K was 0.94, with CVI values for the seven domains ranging from 0.8 to 1, indicating satisfactory content validity, which exceeds the findings reported from Malaysia.^[17] The CVI of PoDLiS-K is consistent with findings from Huang et al.^[18] and Guo et al.,^[19] thus indicating a robust implementation of the validation inputs. The excellent content validity underscores the PoDLiS-K as a valid tool for assessing PPD literacy among Kannada-speaking populations, enhancing its potential for effective application in both clinical and community settings.

CONCLUSION

This study is the first exploration to culturally adapt, translate, and validate PoDLiS to a vernacular language within the Indian context. It attempted to culturally adapt the PoDLiS to Kannada and also established good reliability and excellent validity, proving it to be a reliable tool for assessing PPD literacy among mothers in community settings in India. It can further serve as a valuable instrument to evaluate the effectiveness of interventions aimed at enhancing PPD literacy in India.